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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This farm is intended for trse by contractors performing annual testing of UST spill containment structures. The completed' <br /> and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator,for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: TOKAY KWIK SERVQ Date of Testing: 01-31-18 <br /> Facility Address: 420 KETTLE MEN BLVD LODI CA <br /> Facility Contact: NOCK Phone: 209-369-2790 <br /> Date Local Agency Was Notified of Testing:01-16-18 <br /> Name of Local Agency Inspector(rf present during testing): SAN JOAQUIN CO <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2111 Street Galt, CA 95632 (209)744-0112 Fax: (209)744-0116 <br /> Technician Conducting Test: []Ed Sterns ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G. Ramirez <br /> 814188-UT 8211269-UT 5263373-UT 5273934-UT <br /> Credentials: ❑ ICC Service Tech. ❑ SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: <br /> Identify Spill Bucket (By Tank I WASTE OIL 2 3 4 <br /> Number, ,Stored Product, etc. <br /> ®Direct Bury El Direct Bury <br /> ❑ Direct Bury ❑ Direct Bury <br /> Bucket Installation Type: ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in ❑ Contained in <br /> Sump Sum <br /> Bucket Diameter: 11 <br /> Bucket Depth: 12 <br /> Wait time between applying <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1300 <br /> Initial Reading(Ri): 12 <br /> Test End Time(TF): 1400 <br /> Final Reading(RF): 12 <br /> Test Duration(TF—Ti): 1 HOUR <br /> Change in Reading(Rr=-RT): 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: ® .Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(inchrde inforinalion on repairs made prior to testing, and recomruerrdcdfollotF-up forfailed tests) <br /> OPW BUCKETS <br /> CERTIFICATION OF TECHNICIAN RLSPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that Al the information contained in this report is true,accurate,and ni full conipliunce with legal requirements. <br /> Technician's Signature: ll Date:01-31-18 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />